Cardiac electrophysiology (EP) is evolving quickly and data presented this year at ACC.26, European Heart Rhythm Association (EHRA 2026) and Heart Rhythm Society (HRS 2026) suggest practice may change just as fast. Across stroke prevention, ablation, pacing, ventricular arrhythmias and site-of-service decisions, five themes emerged as most likely to shape EP in the near term.

Stroke prevention in AFib has become more nuanced.

Oral anticoagulation (OAC) remains first-line for stroke and systemic embolism (SE) prevention in atrial fibrillation (AFib). OCEAN and ALONE-AF, however, suggest AFib ablation and/or left atrial appendage occlusion (LAAO) may be reasonable alternatives to continuing OAC.¹

However, an OCEAN substudy presented at EHRA 2026 revealed a 6% annual AFib recurrence rate after ablation. These episodes were brief, infrequent and not associated with an increased risk of stroke.²

CLOSURE-AF raised concerns that physician-directed standard care (primarily with OAC) was superior to LAAO for a composite endpoint of stroke, SE, cardiovascular or unexplained death, or major bleeding.¹ Yet, LAAO was shown to be noninferior to OAC for a compositive endpoint of stroke, SE and cardiovascular death in CHAMPION-AF.³ Of note, a higher, nonsignificant rate of ischemic stroke was observed in the LAAO arm (3.2% vs. 2.0%).

A subsequent CHAMPION-AF substudy, presented at HRS 2026, determined that patients with prior AFib ablation and LAAO had the lowest rate of ischemic stroke/SE (1.9%), vs. prior ablation with OAC (2.4%), no prior ablation with OAC (2.1%) and no prior ablation with LAAO (4.5%).⁴

PFA to become the new standard for ablation.

Pulsed field ablation (PFA) quickly moved from promising alternative to likely new standard in catheter ablation (CA) over thermal energy sources.

The PFA Live Summit at HRS 2026 showcased over a dozen new or existing PFA catheters for the treatment of novel ablation targets in AFib, atrial flutter, ventricular tachycardia (VT) and concomitantly with LAAO. And, six late-breaking clinical trials featured PFA performance in the treatment of paroxysmal AFib (variable loop circular catheter), persistent AFib (AVANT GUARD), and VT (Sphere-9 catheter), as a dual-energy ablation catheter for AFib (FlexPulse IDE Study) and for VT (Sphere-9 catheter), and as nanosecond delivery catheter (CellFX nsPFA-360 catheter).⁵

Similarly, the PFA Summit at EHRA 2026 highlighted the technology, foundation, clinical evidence and application of PFA, and late-breaking clinical trials showed its safety and efficacy against cryoablation in paroxysmal AFib (FACIL-AF, PERFECT-AF, SINGLE SHOT CHAMPION) and radiofrequency ablation in persistent AFib (BEAT PERS-AF).^2,6

Conduction system pacing continues to gain momentum.

A similar shift is underway in conduction system pacing (CSP), which has evolved from His-bundle pacing to left bundle branch area pacing (LBBAP) with dedicated implantation tools to address technical challenges.

LBBAP has become preferred over right ventricular pacing, supported by trials such as LBBP-FAVOUR, presented at HRS 2026, and as an acceptable substitute for CRT with biventricular pacing, supported by trials such as LECART and LEFT-BUNDLE-CRT, presented at EHRA 2026.^5,7 Furthermore, CSP has been adopted in ICD implants and is undergoing evaluation in leadless pacemakers, supported by ASCEND CSP and LEAP2, respectively, presented at HRS 2026.⁵

CA favored in ventricular arrhythmias.

Ventricular arrhythmias have become more amenable to treatment with CA given advances in ablation technique. This was best illustrated by multiple LBCTs at HRS 2026. Radiofrequency (RF) catheter ablation was superior to antiarrhythmic drug therapy to reduce recurrent VT in ischemic or nonischemic cardiomyopathy (51% vs. 71%, p=0.054) in CAAD-VT.⁵ A more provocative study suggested a single CA could potentially obviate the need for ICD implant in patients with VT and structural heart disease with LVEF ≥40%.⁸

 Other notable trials included use of ultra-low temperature cryoablation system to treat VT (FULCUM-VT); intramural RF ablation guidewire to treat intramural VT (VINTAGE VT); and dual energy (PF/RF) lattice-tip catheter to treat VT and premature ventricular contractions.⁵

ASCs provide new location for ablation procedures.

The landmark decision this year by the Centers for Medicare and Medicaid Services (CMS) to approve cardiac ablation in ambulatory surgical centers (ASCs) is expected to shift a portion of outpatient hospital-based AFib ablation procedures there. Substantial debate remains on safety and quality of ASC workflow, whether additional EP credentialing for ASCs should be considered and uncertainty on how to incentivize EP involvement.

The joint ACC/HRS Scientific Statement: Guiding Principles on the Performance of Intracardiac Ablation Procedures in Ambulatory Surgical Centers provides guidance.

Download the full document.

References

1. To Anticoagulate or Not Anticoagulate: That is the Question. Cardiology Magazine. March 2026. Available here.
2. OCEAN Substudy. Presented at EHRA 2026 on April 12, 2026. Available here.
3. CHAMPION-AF: An Uneasy Win For Watchman Device. AC.org. Expert Analysis. Available here.
4. Ellenbogen KA, Leon M, Nair DG, et al. Outcomes of Left Atrial Appendage Closure vs oral Anticoagulation in Patients with Atrial Fibrillation and Prior Ablation: A Sub-Analysis of the CHAMPION-AF Clinical Trial. Presented at HRS 2026. Abstract Available here.
5. PFA Live Summit. HRS 2025 Late-Breaking Clinical Trials, Available here.
6. PFA Summit. EHRA 2026. Late-Breaking Clinical Trials, Available here.
7. Qiu N, Liu X, Wang Z, et al. Randomized trial of left bundle branch pacing vs right ventricular pacing in vulnerable cardiac function. JACC. 2026;Apr 23:S0735-1097(26)06200-5. 
8. Li M, Zhou D, Ju W, et al. Catheter Ablation versus Implantable Cardioverter-Defibrillators for Hemodynamically Tolerated Ventricular Tachycardia in Patients with Preserved or Mildly Reduced Left Ventricular Ejection Fraction: A Multicenter, Long-Term Cohort Study. Presented at HRS 2026. Abstract Available here.
9. Shanker AJ, Jones SO, Aryana A, et al. HRS/ACC Scientific Statement: Guiding Principles on the Performance of Intracardiac Ablation Procedures in Ambulatory Surgical Centers. JACC. 2026;87(14):1827-1844.

Clinical Topics: Arrhythmias and Clinical EP, Cardiovascular Care Team, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias

Keywords: Cardiology Magazine, ACC Publications, CM-Jul-Aug-2026, Heart Conduction System, Ablation, Electrophysiology, Cardiac Pacing, Primary Prevention